Fat Free Media?

A couple of days ago I was interviewed by Judith Timson, a columnist for the Globe & Mail, who wanted to know if all the talk about obesity in the media was actually helping anyone. You can read her take on this here.

So Judith is going to go on an Obesity Media Diet - i.e. she is not going to read any more media reports on obesity.

While that may or may not help Judith, she does raise a couple of important points in her column:

1) Bombarding the public daily with supposedly new findings on obesity is probably not helpful - only adds to the noise, confusion and fatigue (a la Yellow/Amber/Red Alert! In the end who cares?)

2) Let's make sure that we don't throw out the baby with the bathwater - the problem is not simply excess weight and not everyone with a couple of extra pounds is "obese" or needs "obesity treatment". (You need more than a scale or tape measure to diagnose obesity).

3) Let's not underestimate the negative effect that "healthy-weight" messaging may have on eating and exercise behaviour - if you are looking for "cosmetic" weight loss - you need help with your self esteem and body image - not help with losing weight!

Great points - very much part of a healthy discussion.

I of course will continue reading new stuff on obesity - after all, what could be more interesting?

AMS

What do Patients Expect of Bariatric Surgery - Too Much or Not Enough?

There is no question that with improved results, patients and physicians are beginning to look at bariatric surgery as a realistic and definitive option for the treatment of morbid obesity.

However, do even well-informed patients have the right expectations? This issue was recently addressed by Andrea Bauchowitz and colleagues from the University of Virginia, who examined weight loss expectations of 217 consecutive preoperative patients.

It turns out that over two-thirds of patients (65%) had misconceptions about the amount of weight they would lose after surgery. On average, patients thought that they would lose around 80% of excess weight, when in fact a good response to surgery is probably anything greater than 50% of excess weight.

Almost one-third of patients did not look at surgery as a tool to help make dietary changes and increase physical activity - rather, they thought that surgery would merely prevent overeating.

There were likewise misconceptions regarding length of hospital stay and the importance of post-surgical depression.

Overall, the results of this study show that many patients have misconceptions about the amount of weight loss they can expect from surgery and do not appreciate the need for lifestyle changes after surgery.

Therefore, implementing a thorough patient education program that fosters adequate knowledge about the nutritional and behavioural aspects of surgery as well as the amount of weight loss to be expected may be an important part of preparing patients for surgery.

A previous paper by Bauchowitz, where she examined how bariatric programs evaluate and interpret the psychosocial situation of patients with regard to surgery is available online (click here for full-text). While this study does not tell us whether centres which demand more of their patients have better outcomes, it does provide a list of common practices and things to think about when preparing patients for surgery.

AMS

Caps off to CABPS

It is now widely agreed that looking after obese patients is far more sophisticated than simply advising patients to "eat less and move more".

In fact, the field of bariatrics is rapidly growing into an entity of its own, not just with regard to bariatric surgery but also with regard to bariatric medicine, bariatric nursing, bariatric psychology, bariatric nutrition and other relevant aspects of bariatric care.

It is therefore with great pleasure that I announce the launch of the Canadian Association of Bariatric Physicians and Surgeon's (CABPS) new website at www.cabps.ca

The mandate of CABPS is:

- To bring together Canadian Physicians and Surgeons with a special interest in Bariatric Medicine and Surgery in order to maintain and improve the standards of Bariatric care in Canada.

- To support both primary and continuing educational programs in Bariatric Medicine and Surgery.

- To advance knowledge in the field of Bariatric Medicine and Surgery.

- To facilitate and promote research in the field of Bariatric Medicine and Surgery.

- To develop policies and new ideas in the areas of clinical care, education, and research in Bariatric Medicine and Surgery.

- To represent the views of the Bariatric Physicians and Surgeons of Canada.

- To facilitate communication between the public, the medical community and the ministries of health at the provincial and federal level so as to promote awareness of the health risks of obesity and severe or morbid obesity, the financial and health burden to the individual and to society, and the efficacy of medical and surgical treatment options.

Membership in this organisation is open to all physicians and surgeons with an interest in bariatric care.

Membership (at reduced cost) is also open to all allied health professionals, residents and trainees working in related areas.

Membership forms can be downloaded from the site.

AMS

Obesity in Pre-Schoolers: Dads Matter Too!

Those of you following my blog may have noticed my concern about how maternal obesity and lifestyles seem to impact future risk of childhood obesity.

Well, apparently it's not just Mom's "fault" - Dads matter too!

Melissa Wake and colleagues from the Royal Victoria Hospital in Victoria (AUS) studied the relationships between BMI status at ages 4 to 5 years and mothers' and fathers' parenting dimensions and parenting styles.

Participants were composed of all 4983 of the 4- to 5-year-old children in wave 1 of the nationally representative Longitudinal Study of Australian Children with complete BMI and maternal parenting data.

Mothers and fathers self-reported their parenting behaviors on 3 multi-item continuous scales (warmth, control, and irritability) and were each categorized as having 1 of 4 parenting styles (authoritative, authoritarian, permissive, and disengaged) using internal warmth and control tertile cut points.

They found that while mothers' parenting behaviors and styles were not associated in any model with higher odds of children being in a heavier BMI category, higher father control scores were associated with lower odds of the child being in a higher BMI category.

Thus, compared with the reference authoritative style, children of fathers with permissive and disengaged parenting styles had higher odds of being in a higher BMI category (~30-50% greater risk depending on the statistical model).

Apparently these findings are consistent with a previous intervention study by Stein et al., which showed that fathers' but not mothers' parenting (warmth and support) predicted better maintenance of weight loss after a behavioral parenting intervention for pediatric obesity.

These authors suggest that fathers' parenting may well be an important determinant of the extent to which the family environment as a whole is supportive of children's attempts to lose weight.

Message to Dads: "Get involved - you count!"

AMS

Recommend and They will Exercise - Or will They?

A major strength of the Weight Wise program lies in our links to Community Partners, who offer all forms of exercise ranging from walking clubs to personal trainers.

The question however is - how many patients, who get exercise recommendation from their doctors (or other health professionals), will actually follow through?

This issue was recently addressed by Willams and colleagues from the Centre for Health Sciences Research, Cardiff University, UK, in a Systematic Review. The eighteen studies reviewed included six RCTs, one non-randomised controlled study, four observational studies, six process evaluations and one qualitative study. Results from five RCTs were combined in a meta-analysis. There was a statistically significant increase in the numbers of participants doing moderate exercise with a combined relative risk of 1.20 (95% confidence intervals = 1.06 to 1.35).

This means that 17 sedentary adults would need to be referred to an exercise program for one of them to become moderately active.

On one hand this may sound frustrating (imagine the time spent on advising exercise to patients), on the other hand a Numbers Needed to Treat (NNT) of 17 is actually not worse than many of our medical treatments.

Of course the obvious barriers were identified: time, cost, distance, motivation, etc. Furthermore, exercise behaviour depended upon physical capacity to exercise; exercise beliefs and other factors such as enjoyment, social support, priority setting and context.

Interestingly, in another paper, the same group identified four types of patients: ‘long-term sedentary’ who had never exercised; ‘long-term active’ who continued to exercise; ‘exercise retired’ who used to exercise, but had stopped because of their symptoms (e.g. osteoarthritis), and because they believed that exercise was damaging their joints; and ‘exercise converted’ who recently started to exercise, and preferred a gym because of the supervision and social support they received there. This article is very much worth reading and the full text can be accessed by clicking here.

AMS

421 Pounds

Anyone interested in the trials, tribulations and catastrophic untimely death of one of my Hamilton patients, can read about her in a Special Report (4 parts) starting today in the Hamilton Spectator.

The story illustrates not just how complex treating morbid obesity really is but also demonstrates how failing to deal with obesity as a chronic disease early in its course can only lead to catastrophic outcomes. 

The fact that in the end Cheryl died soon after receiving the long-awaited by-pass surgery should not dispel the benefits to be derived from this procedure. As the story illustrates, outcomes are as (if not more) dependent on proper follow-up and the infrastructure to deal with complications (when they arise) as on finding a willing and able surgeon. 

In isolation, obesity surgery is doomed to failure. On the other hand, as part of a comprehensive program that ensures appropriate patient selection, preparation and long-term follow-up, the results are nothing short of spectacular.

As anyone who has heard me speak about the Weight Wise program should appreciate by now - obesity surgery, even when necessary, is NEVER just about surgery!

AMS

Weighing in on Green Health Care

Despite the risk of being considered a "left-wing tree hugger" here is a post on how health care can go green.

Many of us may not realise this, but health care is a considerable source of environmental pollution and waste. As discussed in a recent Perspectives article in JAMA, a variety of organizations and coalitions are now coming together to help the growing number of hospitals and clinics that are adopting ways to become more efficient and less detrimental to the environment.

For e.g. Kaiser Permanente in the US, is now following the Green Guide for Health Care and has in the last 5 years chosen ecologically sustainable materials for 2.7 million sqm in new construction, preventing 70 billion lbs of air pollution each year. They have also eliminated the purchase and disposal of 40 tons of hazardous chemicals and saved more than $10 million per year through energy-conservation strategies. Interestingly, they are also making a concerted effort to buy food and products locally. (regular readers of this blog will recognize the importance of this last point - if not, click here).

Not to be outdone, Capital Health's own Mazankowski Heart Institute, due to open in 2008, will be a "green building," equipped with energy-saving equipment like occupancy sensors that turn off lights in empty rooms and giant heat recovery wheels that strip heat from air before it is exhausted to the outside. Capital Health estimates that these features can reduce costs to run the building by $1 million per year. The energy-saving features will also increase the likelihood of the Heart Institute becoming the first hospital in Canada to achieve LEED silver certification (Leadership in Energy and Environmental Design).

To be LEED certified, a building earns points for innovative design features that promote a healthy environment, reduce costs and prevent wastage. For example, green spaces on the Heart Institute's various rooftops will reduce heat reflection, and underground water tanks will collect runoff rainwater so it can be used for non-sterile tasks like hosing down sidewalks. The building will also get points for encouraging alternative, environmentally-friendly transportation through its proximity to Edmonton's new subway station and for providing lockups for bicycles. It will have bright, open stairwells which promote use for staff and able-bodied visitors, rather than energy-expending elevators.

Although WW is certainly eons away from being the prime source of waste in the CH system, we certainly produce a lot of paper, educational and promotional materials, and do use some disposable supplies. Over time all of this can certainly accumulate in appreciable piles of waste.

For anyone wanting more information on Green Healthcare check out the following:

Health Care Without Harm: A global coalition to reduce pollution in the health care industry.

Hospitals for a Healthy Environment: Educating health care professionals about pollution prevention and environmentally sound practices.

While WW is certainly mainly about WAIST management - let's not forget about also managing our WASTE!

AMS

Certification of Exercise Physiologists

My recent post on the role of personal trainers in obesity management elicited a number of e-mail responses.

From the mail that came in, the following information is perhaps especially worth noting:

As many of you know, The Canadian Society for Exercise Physiology (CSEP) is a voluntary organization composed of professionals interested and involved in the scientific study of exercise physiology, exercise biochemistry, fitness and health. On November 17, 2007 (at the national CSEP conference in London, Ontario) the following supplement was released: Advancing the Future of Physical Activity Measurement and Guidelines in Canada: a scientific review and evidence based foundation for the future of Canadian physical activity guidelines.

To view the supplement click here

If you are a CSEP member, you will be receiving a hard copy of the supplement in the mail.

Hat Tip to Taniya Birbeck, Exercise Specialist, Capital Health Weight Wise Program, for bringing this to my attention.

AMS

Is Reducing Global Warming the Key to Preventing Obesity?

The link between two major problems of our times, global warming and the obesity epidemic, may be closer than we think. 

The following are a few random thoughts on why I believe solving one will go a long way to solving the other.

If we accept that a major contribution to the rising incidence of obesity is (energy) overconsumption and lack of physical activity, then reducing consumption and increasing physical activity will be important. 

But reducing consumption and increasing physical activity will also help reduce global warming - here is why:

Over the past century, fossil fuels have increasingly displaced food as the energy source for human movement. Both occupational and domestic physical activity has been replaced by automation and labor-saving devices, all of which consume energy from fossil fuels.  But not just automation, also the physical effort to move from one place to another is today largely dependent on fossil fuels.

As people get larger the fuels consumed to move the extra weight around only adds to the problem. It was estimated that in 2000,  US airlines spent $275 million to burn 350 million more gallons of fuel just to carry the additional weight of Americans. Obviously, it also takes more fuel to move heavier people around on the ground whether this is in cars or on elevators, escalators or amusement park rides. 

But increased use of fossil fuels is not just part of the activity equation. The use of fossil fuels is also intimately linked to our food. World-wide, agricultural activity, especially livestock production (including ruminant methane production, transport and feed), accounts for about one fifth of total greenhouse-gas emissions.

In most industrialised countries today the total energy put into food production vastly exceeds the food energy yield [see McMichael et al. for in depth discussion of this topic].

As energy inputs, mainly in the form of fossil fuels, have gradually increased, the energy ratio (energy out/energy in) in agriculture has decreased from being close to 100 for traditional pre-industrial societies to less than 1 in the present food system. Each calorie of food you eat may have consumed 10 to 50 calories in fossil fuels (the exact number depends on how you calculate this relationship - but no matter how you do it, the numbers are scary). 

Processing 1 pound of coffee requires more than 8,000 calories of fossil fuel, the equivalent of one quart of crude oil, 30 cubic feet of natural gas or 2 1/2 lbs of coal.  It has been estimated that the CO2 emissions attributable to producing, processing, packaging and distributing the food consumed by a family of four is about 8 tonnes a year. (For more on this click here).

Not surprisingly, many environmental organisations are now targeting built environments, transportation as well as food production and supply as major culprits in global warming. How do some of these issues relate to obesity prevention?

Rebuilding our cities to allow shorter trip distances will also allow changes in travel mode (e.g. walking or bicycling instead of driving). When it comes to both  the environment and to obesity, urban sprawl is a killer! 

Compact densely populated neighbourhoods where the majority of trips can be done by active transport paired with efficient urban public-transport systems powered by renewable energy would not only reduce local air pollution and greenhouse emissions but would also reduce traffic injuries and improve the safety of neighbourhoods (more people on the street!). 

Creation of human-scale, mixed-use urban "villages" with unique identities, improved local services, neighbourhood events and activities, accessible public transport including high-quality pavements, cycle paths, lighting and public art will get people out and moving - thereby reducing both greenhouse gases and increasing physical activity. (for an in-depth analysis of these issues refer to Woodcock et al. in the Lancet series on Energy and Health). 

Perhaps the key to both global warming and the obesity epidemic may be in living, working and eating local. 

Is this utopia? To some perhaps, but the alternative is scary!

AMS

Kudos to Dr. Padwal!

At least publication wise, this has been a great week for our Dr. Padwal.

In an article published in the BMJ he analysed the overall utility of anti-obesity drugs. The bottom line is that on average the results of using these drugs, when assessed by the magnitude of weight loss compared to placebo, is rather modest.

Of course this story was widely picked up by the media (click here for TIME Magazine's take on this).

In the October issue of IJO Dr Padwal also had a paper on adherence to anti-obesity meds (click here for the link to PubMed). The bottom line here was that although effective, most people take their medications only for a few months, after which weight comes back.

Both articles raise important issues regarding obesity treatments in general.

1) Should "average" efficacy determine choice of therapy?

When dealing with a condition that is as heterogeneous as obesity, can any single non-pharmacological (lifestyle) or pharmacological intervention be expected to produce dramatic average effects?

For e.g. cognitive behavioural therapy (CBT) appears to work well for people with binge eating, but there is little evidence that it works for obesity in general.

Similarly, sibutramine, which works largely by enhancing the physiological satiety response to eating, works in some patients but not in others. So for e.g. I frankly do not expect sibutramine to work in patients where poor satiety is not the problem (e.g. in hedonistic eaters), in people who are eating too fast to allow their physiological satiety response to kick in (by which time, they have already consumed too many calories), or in people who have no physiological satiety response (e.g. mutations in the MC4 receptor).

In clinical practice it is common experience that individual patients will do better on one treatment than on others (in fact, we call that "personalized" medicine).

It is important to realise that when dealing with an epidemic, even a small fraction becomes a large number of patients. So even if only 20% of obese patients do well on CBT, sibutramine or orlistat (and these are most likely a different 20% for each treatment), respectively - that still means that these approaches could be effective in millions of patients.

I believe that the problem with obesity treatments in general is not that they do not work - the issue is that all treatments just don't work for everyone!

Identifying patients for whom specific interventions work better than others remains a key challenge although there have been pragmatic suggestions: if one treatment does not work - try something else!

2) Should treatments be abandoned because patients don't stick with them?

This is not just an important question to ask about pharmacotherapy (as Dr. Padwal did in his IJO paper). The question is as relevant to non-pharmacological treatments.

So if the majority of patients will not adhere to a given treatment in the long-term (we call this attrition), should we completely abandon using this treatment?

Of course not! Thus, although there is little evidence that the majority of patients will stick to lifestyle treatments in the long-term, some people will (e.g. the folks on the National Weight Loss Registry) and for them this approach is reasonable. For the rest, we are going to have to do better.

The case for pharmacotherapy is not different. Just because most patients will not take their anti-obesity drugs forever, does this mean we do not use drugs at all? Some patients will stick to their medications and for them this is certainly an effective treatment.

Incidentally, it may be worth noting that there is nothing unique to obese patients in terms of not sticking to treatments - this problem is universal to all chronic diseases. Thus patients with hypertension, diabetes, high cholesterol and even patients with painful conditions such as rheumatoid arthritis are notorious for not sticking with their prescribed treatments for more than a couple of months.

I believe that as patients, health professionals and regulators move towards thinking about obesity as a chronic disease rather than something we can "fix" with a short-term approach and as we fully realise that in obesity management "one size will not fit all", we will eventually become more effective (and realistic) in dealing with this condition.

AMS

Should All Personal Trainers be Allowed to Treat Obesity?

In today's edition of CMAJ there is a statement worth noting regarding the qualifications that exercise professionals should have before being allowed to work with obese individuals.

The basic point of this statement (co-signed by a number of prominent Canadian Kinesiologists and Exercise Physiologists) is that because many overweight and obese individuals are at an increased risk of various co-morbidities, including cardiovascular disease, it is imperative that exercise professionals involved in treating such individuals have a clear knowledge of the absolute and relative contraindications to exercise for patients with obesity.

The authors strongly believe that such knowledge can only be developed through formal and rigorous post-secondary academic training within a faculty of exercise science, which is in clear contrast to some personal training designations provided by "for-profit" organizations that do not require advanced college or university education in health or exercise science. In their statement, the authors go on to describe what they feel is an acceptable standard of qualification and certification that will best ensure patient safety.

The points are certainly well taken and I fully agree that dealing with obese patients in particular requires sound medical knowledge and expertise in exercise physiology.

Not only are obese patients at increased cardiovascular risk, but they are also at extreme risk for mechanical injury due to lack of flexibility, balance and coordination, particularly during weight-bearing exercises. Existing back, hip and knee problems can easily be exacerbated by a misguided "boot-camp-drill-sergeant" approach to "let's-burn-off-those-calories".

Immobility resulting from musculoskeletal injury caused by improper and overzealous exercise routines can only exacerbate obesity and cardiovascular risk factors and will certainly pose a direct threat to effective weight management.

The much bigger question here is not just about personal trainers or self-appointed exercise gurus but rather about the entire for-profit "weight-loss industry".

While there is certainly an important and often invaluable role for lay-persons in peer-support groups, buddy systems and walking clubs, the fact that patients often have no way of recognizing qualified from unqualified health professionals can indeed pose a health hazard, particularly for obese individuals who will clutch at any straw for help.

The key question indeed is that if obesity is really a disease, should someone who is not a certified and regulated health professional be allowed to offer treatment? Can we forbid self-appointed "health advocates" to offer their services? Probably not. Would we recommend that our patients seek help or advise from individuals with "iffy" qualifications? Not likely.

An important function of WW will be to help patients find community services that help them improve their health (with or without weight loss!) without putting themselves at risk.

Clearly, the bigger the patient, the greater the risk - self-imposed limitations and/or legal restrictions on working with clients above a certain size may well be in the interest of anyone working in this industry who does not have the training and credentials to work with obese clients.

AMS

Maternal Obesity and Neonatal Risk

Many of you are probably aware of the increasing discussion on the role of maternal obesity and excessive pregnancy-related weight gain as a key risk factor for childhood obesity.

In fact, some folks now seriously believe that this is the real reason why the pediatric obesity epidemic appears to be spiraling out of control.

Both animal studies and human observational data strongly support the notion that intrauterine epigenetic modification together with early post-natal influences on brain development may play an important role. A joint researcher team from the UofA and the UofC currently has a team grant in on exactly this issue.

Now a recent study from Denmark delivers another important reason for addressing maternal obesity. Nohr and colleagues, examined the relationship between prepregnancy BMI and neonatal mortality in 85,375 liveborn singletons of mothers in the Danish National Birth Cohort (1996-2002). Information about pregnancy outcomes and neonatal deaths (n=230) was obtained from national registers. Compared with infants of mothers who were at a normal weight before pregnancy, neonatal mortality was increased in infants of mothers who were overweight or obese (adjusted hazard ratios 1.7 and 1.6, respectively).

This observation of increased infant risk with maternal obesity is very much in line with previous reports, for e.g. a study by Heddersen and colleagues, who analysed a cohort of 45,245 women who delivered singletons at Kaiser Permanente Medical Care Program Northern California in 1996–1998 in which women who gained more than recommended by the IOM were three times more likely to have an infant with macrosomia than women whose weight gain was in the recommended range.

This is relevant to us, because currently about 10% or mothers in our health region are obese. Should WW be working with the maternal and neonatal program on this? I reckon this is well worth looking at.

Indeed, if there is any merit to these recent findings then aggressively targeting maternal obesity may help break the trans-generational obesity cycle and prevent obesity in the next generation.

AMS

Does Weight Matter?

Some of you may have seen the news items in yesterday's media - a new study by Flegal et al. from the CDC, published in the Nov 7 Issue of JAMA, finds that overweight individuals (BMI 25 to <30) have significantly reduced mortality from non-cancer and non-CVD deaths and no increase in risk for death from all cancers or CVD (compared to normal weight (BMI 18.5 to <25) individuals). The results are based on an analysis of NHANES I, II & III.

I was interviewed on this paper by several media representatives and in general my take on this was:

1) BMI (a measure of weight) is a poor measure of overall health
2) More important than the amount of excess weight (especially for overweight individuals) is where it is located

Obviously, this study will lead to a lively discussion and provide to ammunition to all who claim that the obesity epidemic is being dramatized and overrated.

For us the implications are probably as follows:

1) let's remember that weight is just a number on the scale
2) healthy eating and active living is possible (and advisable) at any weight
3) skinniness is not a guarantee for longevity

This however, should not distract us from the fact that excess weight (fat) can significantly impact on health and that therefore preventing or treating obesity in individuals where excess weight threatens or affects health is important.

Hope you'll have time to catch the CFR,

AMS

Flying Blind?

I've posted before on the fact that Calories are the currency of weight management - if you don't know how many Calories are coming in and how many are going out, how can you actively manage your Calorie account (read: weight!)?

As most of us eat many of our meals outside the home, getting restaurants to post calories (not simply on some obscure website or on some pamphlets that you have to ask for) is a major topic of discussion amongst obesity experts.

I was therefore particularly pleased that the CBC yesterday chose to devote its edition of Marketplace to the fact that restaurants make it hard (if not impossible) for consumers to actually find out exactly what they are ordering from the menu.

For those of you, who missed it I suggest watching it online!

Those of you working on the "Finding Balance" module - take note - may find some interesting ideas here.

AMS

p.s. Dr. Yoni Freedhoff, author of "Weighty Matters" is featured on this show

Barriers to Bariatrics?

So today we discussed how to best rename the combined Adult Weight Management Clinic at the Alex, which would provide all aspects of tertiary obesity care (behavioural, medical & surgical).

An obvious suggestion was Weight Wise Adult Bariatric Clinic (WW-ABC).

The question was, would people then assume that this is a purely surgical clinic as the term "bariatric" is generally associated with surgery?

Well, the fact of the matter is that the term "bariatric" is actually simply the proper medical terminology for the branch of medicine that deals with the causes, prevention, and treatment of obesity. It stems from the Greek root baro ("weight," as in barometer) and suffix -iatrics ("a branch of medicine," as in pediatrics or geriatrics).

The term "bariatrics" is increasingly used to describe all aspects of obesity care including:

• bariatric nursing
• bariatric psychiatry
• bariatric pharmacology
• bariatric psychology
• bariatric furniture
• bariatric rehabilitation
• bariatric skin care
• bariatric research
• etc.

So if "bariatrics" is the official term for obesity care, then this should be an obvious choice as a name for the clinic (after all, that's what we do).

Will people understand what this means? I guess we'll have to teach them.

Appreciate all comments and takes on this!

AMS

Getting to Goal

This morning we had a "dry run" of the first module for the community "group visit" - the topic was identifying your goal. The idea is that patients need to think deeply about why it is they want to be in the WW program. Wanting to lose weight is not good enough - patients would need to be quite explicit on why they'd want to lose weight and what exactly it is they want to achieve by getting the pounds off. They also need to recognize potential barriers and plan strategies on how to overcome these.

The community team came up with a fantastic script - very well thought through, lots of interaction, great ideas - now we need a couple of pilot sessions to see how things flow, but I am confident that this group visit will make a big difference as we proceed with restructuring the WW program towards delivering effective bariatric care.

Great job everyone! Looking forward to the next "modules",

AMS

The Six Natural Laws of Weight Gain

With all the talk of "thrifty genes" and how our "hunter-gatherer genome" is overwhelmed by the "obesogenic" environment, it may be time to revisit my favorite theories about the "Natural Laws of Weight Gain".

This is something I came up with almost 10 years ago and have used in a lot of talks over the years. I've always wanted to put these ideas into a book but somehow never got around to it.

Simply stated, my Six Natural Laws of Weight Gain are as follows:

1. Always eat when food is around
2. Always go for the gravy
3. Always eat as fast as possible
4. Always eat as much as possible
5. Don't move if you don't have to
6. When fuel runs short, turn down the furnace

If anyone is thinking, "hey, that's me", you're probably not alone (in fact it's me too!).

If you take a minute to think about it, you'll probably recognize just how deeply these Natural Laws are engrained in our biology and culture and may realize how we've actually designed much of our environment to accommodate these laws.

Suddenly terms like "mindless eating", "fast"food restaurants, "all-you-can-eat" buffets, "poutine", "super-size it" and "couch potato" take on a whole new meaning.

While through the millennia of evolution these Natural Laws guaranteed the survival of our species, in our current obesogenic environment, they also pretty much guarantee weight gain.

As I have often pointed out in my talks: "In today's obesogenic environment, people have to develop "abnormal" behaviors to avoid gaining weight".

Doing things that came "naturally" to most of us is a surefire recipe for weight gain - in today's enviroment, fighting obesity literally means going against our "nature"! No wonder it is so hard to do.

OK, I realize that by now some of you are screaming that this must be wrong, that I am grossly oversimplifying the complex psychosociobiology of obesity, and that I am just providing obese people with an easy "excuse" to blame it all on nature.

Of course I realize that in reality things are way more complex and that there are many paths that lead to obesity ranging from childhood molestation to antipsychotics or from genetic defects to endocrine abnormalities (the list of possible causes if far longer than you may think!).

Nevertheless, I do believe that perhaps with the exception of such "special causes" the Natural Laws do provide a reasonable and useful framework for thinking about the root causes of the current obesity epidemic.

So in the next couple of weeks, I will be occasionally revisiting this theme and hope to explore some of these laws and how they apply to our current dilemma.

Perhaps the title of my book should be: "The Six Natural Laws of Weight Gain and How to Break Them"!

I wish someday to actually find time to write it - I could probably have a lot of fun with this.

AMS

Dr. Kushner's Personality-Type Diet

At the recent Obesity Society meeting in New Orleans, I had a long chat with Dr. Robert Kushner, Professor of Medicine, Northwestern University Feinberg School of Medicine, Medical Director, Northwestern Memorial Hospital Wellness Institute and Past President, American Board of Nutrition Physician Specialists. He is also the incoming President of the Obesity Society (formerly NAASO).

The reason I bring this up is because I has the opportunity to listen to Dr. Kushner's ideas on "personalizing" obesity treatments. As I understand it, his point is that it is not enough to consider motivation or readiness for change. One also has to consider personalities, as no matter whether or not someone is ready or not, their personality cannot be ignored and may pose an important barrier.

This is not simply about "high achievers" or "low achievers" or "introverts and extroverts". It is more about whether or not you are a:

• Hearty Portioner or an Unguided Grazer?
• Hate-to-Move Struggler or a No-Time-to-Exercise Protester?
• Can't-Say-No Pleaser or an Emotional Stuffer?

Dr. Kushner has a whole bunch of categories (if I recall correctly there are 17 types!) that need to be considered in order to appropriately counsel for weight management. All of this comes with an elaborate personality type test that one can take (66 questions in all) on his website, which also promotes his best-selling book.

I must admit that I have neither read the book nor taken the personality test - but the idea that people's personalities must be considered when counselling on weight management intuitively makes sense.

What I'd like to see now is a study on whether or not including counseling strategies based on Dr. Kushner's personality types actually yields better long-term results than conventional approaches. Knowing Dr. Kushner, I expect that such studies are underway.

AMS

Does Exercise Help With Weight Loss?

This morning, I debated the award-winning US science journalist Gary Taubes on the CBC Sunday TV News about one of the central theses of his new book (Good Calories, Bad Calories) where he challenges the widely held view that exercise is the best way to lose weight.

Actually, Gary and I did not have much of a debate around this issue, as for years I have been telling my obese patients that exercise ALONE will seldom do it for them - weight loss requires negative energy balance, which is hard to achieve without also restricting caloric intake (we did not get into the discussion about which calories to restrict - another interesting discussion altogether).

The normal response to exercise is hunger, which if you respond to, essentially restores your energy balance back to “normal” - so don’t expect to lose weight.

Now of course, this should not be taken as an excuse to stay on the couch - the benefits of a physically active lifestyle are manifold:

• improved insulin sensitivity
• less intra-abdominal (bad) fat
• less stress
• cardiovascular fitness
• better coordination and balance
• less osteoporosis
• less dementia
• etc, etc, etc.

Just don’t expect to see massive (or even any) weight loss - you are more likely to see inches disappear from your waist (as abdominal fat is replaced by muscle and perhaps some subcutaneous fat) but the numbers on the scale will not change - will you be healthier? Most likely!

By the way, although exercise may not be the best way to lose weight - people who are more active are more likely to keep the weight off - and after all, that’s what obesity treatment is all about - if you can’t keep it off, why lose it at all?

Better still to be as physically active as you possibly can and not gain the excess weight in the first place (yes, I know that there are many active people who still put on weight - but just imagine where they would be without that activity?)

AMS

Transforming "Wait" Wise

With over 250,000 obese people living in the Capital Health Region, it should be no surprise that there is currently a waiting list of over 2000 people to be seen in the Adult Weight Management Program (as this is less than 1% of all obese people in the CH Region, I am frankly surprised the list is not far bigger!).

So perhaps it is timely that several of us from WW just spent the last two days at the first of a series of workshops called Alberta AIM (Access Improvement Measures) that should take us from an 18 month waiting list to a "same-day" appointment over the next year or so.

If anyone thinks that this is impossible, you are probably not alone in thinking so, because I am a big a sceptic myself. On the other hand, there is no question that WW could be made a lot more efficient and significantly improve not just the throughput of patients but also the quality of care (however we decide to measure it).

There is no question that much of the effort that goes into managing a waiting list (and the angry, frustrated, disappointed and frantic patients who are in it) could be channelled into better access.

In order to do this we need to look at both macro an micro factors that affect the list. I guess some of the basic questions to ask are:

• Who is waiting?
• What are they waiting for?
• Are they in the correct line?
• Can they be doing things while in the line?
• Do we even need a line?

Well, we've taken back a bit of homework from the workshop (which is just the first in a whole 18 month process of change):

We need to look at "demand", determine our "supply", and look at where we can eliminate inefficiencies that are clogging up the system.

While I may have been sceptical when I first heard I was attending this workshop, I must admit my scepticism has been tempered - in fact, I believe it is fair to say that all of us, who on behalf of WW had the opportunity to attend this workshop, have come away with a huge surge of enthusiasm and optimism that we can turn things around - we have a whole slew of interesting ideas that we will be discussing with all of you over the coming weeks and months.

This will not be a "top-down" change. The biggest (or rather the many small) changes that will really make a difference will be at the front line and will need your help and support. It is going to be a most exciting journey.

AMS

Why health professionals don't like obese clients

It is probably not news to anyone working in a health care setting that dealing with obese clients can be frustrating and at times infuriating. Why can't these people just eat less and move more? How can anyone let themselves get so large? Why can't they simply be "wise" about their weight?

Well, if you or some health professional you know has difficulty in dealing with obese clients, you are not alone. In fact you may be interested that the Obesity Society just released a new slide deck on Weight Bias in Health Care Settings.

In this new slide talk, Rebecca M. Puhl, PhD, and Kelly Brownell, PhD, present the growing body of scientific evidence which demonstrates that weight bias among healthcare professionals has serious, negative impacts on the quality of healthcare services provided to overweight and obese patients in healthcare facilities. They also discuss what providers can do to reduce any bias which they may have in their practice.

This is why we are keen to develop a CH-wide sensitivity training intiative, spearheaded by the WW program, to ensure that no obese client experiences weight-bias or discrimination in the CH region.

AMS

Why I don't like BMI

I often get asked to explain or define the term "obesity". This is when, as a clinician, I am reminded that the conventional BMI-based definition of obesity is problematic.

To be fair, the concept of BMI has been most useful for population studies and there is no doubt that it reasonably reflects average body fat in a given group of people.

Yes, on average someone with a BMI of 30 will probably have more body fat than someone with a BMI of 25, but does this mean that everyone with a BMI of 30 needs obesity treatment and everyone with a BMI of 25 is safe? The diplomatic answer of course is "it depends"!

"Depends on what?" you may ask. Well, it depends on whether or not a) the higher BMI actually reflects more body fat in that individual and b) the person with the BMI of 30 actually needs treatment.

So the question really comes down to - does a given BMI level help me decide who needs obesity treatment? Well, most clinicians will probably agree that taken alone it doesn't. You probably also need to know the age, gender, ethnic background, waist circumference, family history, current complaints (if any) and risk factor profile to decide who needs obesity treatment.

For example, a young pre-menopausal Caucasian woman, physically active, healthy diet, no risk factors with a BMI of 30 may be safe, whereas a 50 year old South Asian male with elevated triglycerides, hypertension, waist circumference of 95 cms, family history of premature heart disease and BMI of 25 may in fact significantly benefit from losing a few pounds (and keeping them off!).

Well, that is not what the current guidelines or regulators tell me - according to them, our BMI 30 lady has "obesity" and would thus qualify for obesity treatment; our BMI 25 male is not obese and would not qualify - nonsense!

So what is obesity? My rather simple clinical definition is the following:

Obesity is that level of excess fat that threatens or affects someones socioeconomic, mental or physical health - obviously, the level of excess fat that does that will vary from individual to individual depending on their "global risk".

In fact, even with other risk factors such as dyslipidemia, diabetes or hypertension, we have now moved towards "global risk" where we factor in age, gender, co-existing disease, past history, etc. If this makes sense for dysplipidemia, diabetes or hypertension, why not adopt the same strategy for excess fat? - too complex for the busy practitioner?

Well, who said medical decision making has to be easy?

AMS

Moving obesity care into the community

With over 250,000 obese people in the region, there is no way that specialists or tertiary care centres like the Adult Weight Management Clinic at the Royal Alexandra Hospital can even begin having an impact on reducing the burden of obesity in the region - there is no question that much of obesity treatment has to happen in the primary care networks and community classes and take full advantage of whatever resources there are for this in the community.

As with all chronic diseases, empowering patients to help themselves requires teaching them the insights and skills to deal with their condition. They also need to be aware of the realistic treatment options in order to make informed choices on what treatments work and how to distinguish weight-loss scams from professional help. This is a huge challenge!

Not only will we need to educate our patients but we also have to educate our health professionals to better understand obesity and teach them how to approach it with the same knowledge base, understanding, compassion and attention that they pay to other chronic conditions. Without a concerted effort at all levels of care, we are not going to provide obesity treatments to a meaningful proportion of the population struggling with excess body weight.

In the end, whether or not we can provide effective obesity treatments in the community will make or break the WW program. Not only do I not see an alternative, but fortunately, I am also confident that it can be done - the sooner we move on this the better.

Obviously, while we think about how to provide better obesity treatments, we should by no means ignore the very urgent task of preventing further spread of this epidemic. This will require both changes in individual behaviours but also massive and profound changes in the current "obesogenic" environment.

Using the analogy of water-borne communicable diseases: yes, we need to get more people washing their hands but we also need to ensure a clean water supply and a functional sewage system.

AMS

Homeostatic Hyperphagic Obesity

Recently I had the pleasure of enjoying a 2 hr walk-'n'-talk with John Blundell (perhaps known to many of you as the ingestive behaviour "guru" from Leeds). He talked to me a lot about his research and how his group had developed a series of tools that would help distinguish "homeostatic" from "hedonistic" eating.

I must admit, that although the concepts were intuitively familiar to me, I had not thought about these issues in such clear terms.

The basic idea is as follows:

There are essentially two different kinds of eating:

1) homeostatic eating - regulated by "hunger" and "satiety"

and

2) hedonistic eating - regulated by "appetite" and "reward"

Let me give you examples:

When you skip breakfast, have a small salad for lunch, and then arrive home "starving" and barely make it to the refrigerator in time to polish off last night's leftover pizza, before going on to eating everything else in sight before that comfortable feeling of "fullness" (read: "satiety") sets in, then you have just experienced "homeostatic" eating - you ate because you were "starving" and rapidly eating large amounts of (junk?) food is nothing but the normal response to being hungry.

On the other hand, when you've just had a three-course lunch and return to your desk only to find that the work you left lying around is still waiting for you as a result of which you suddenly feel the urge to open the secret drawer and finish the bag of chocolates - that is "hedonistic" eating - you ate because of the "pleasure" (read: "reward") that comes from eating a bag of chocolates - this has nothing to do with hunger or energy regulation.

Why is the difference important? Well for one, we know that there are different molecules and receptors responsible for "hunger" and "satiety" than there are for "appetite" and "reward". These systems are in fact so different that the therapeutic approaches to deal with "homeostatic" vs. "hedonistic" eating are bound to be different (will save my thoughts on this for another day).

In any case, the bottom line is that we probably need to actually figure out why a given individual is "hyperphagic" (i.e. eating too much) in order to provide the proper counseling and treatment. Simply put, the solution for "homeostatic" eating may be to correct the eating pattern, thereby avoiding hunger; the solution for "hedonistic" eating may be to develop coping strategies that will help "apease" the reward system without calories - very different approaches indeed.

Well, in real-life things are of course far more complex - most people (like myself?) are probably both "homeostatic" and "hedonistic" eaters - more of one or the other depending on your day.

OK, so who said real-life has to be simple?

In any case, I can't wait to try out John Blundell's "hedonistic tool-box"!

AMS

Weight Wise Integration Tool

OK, the challenge is: can we create a simple tool that will allow busy primary care docs (and non-obesity specialists) to screen for and address obesity management issues in their patients?

The keywords in the last sentence are "simple" and "busy"! No point having a tool that takes 30 mins to work through - let's remember, the average PCP-patient encounter is presumably less than 10 mins.

So what would be a reasonable start? Well for one, it may be worth posing the question of whether or not this patient actually needs obesity management:

Is excess weight currently threatening or affecting this patient’s socioeconomic, mental and/or physical health?

1) Not threatening or affecting
2) Somewhat threatening or affecting
3) Quite threatening or affecting
4) Very much threatening or affecting
5) Definitely threatening or affecting

My guess is that if the answers are 1 or 2, then obesity management should be put on the backburner - monitor weight, counsel on avoiding weight gain, healthy eating, activity, etc. If the answers are 3-5, definitely need to consider addressing obesity management and move to the next question:

Does this patient present barriers to weight management?

1) Insurmountable barriers
2) Strong barriers
3) Moderate barriers
4) Minimal barriers
5) No barriers

I'd assume if the answers are 1 or 2 that this may not be the best time to begin thinking about weight management; if the answer is 3 one needs to see if the barrier can be overcome, if the answer is 4 or 5, well looks like there is no excuse to not start by asking the next question:

Is this patient ready to address excess weight?

1) Not thinking about change, resigned or in denial (Pre-contemplation)
2) Weighing benefits and costs of proposed change (Contemplation)
3) Experimenting with small changes (Preparation)
4) Taking definitive action to change (Action)
5) Maintaining new behavior over time (Maintenance)
6) Experiencing relapse (Relapse)

This one is pretty much based on the Prochaska and diClemente's Transtheoretical "Stages of Change Model" - I like the stage by stage intervention strategies suggested on the UCLA Nutrition site (and undoubtedly countless other sites):

Pre-contemplation:
- Validate lack of readiness
- Clarify: decision is theirs
- Encourage re-evaluation of current behavior
- Encourage self-exploration, not action
- Explain and personalize the risk

Contemplation:
- Validate lack of readiness
- Clarify: decision is theirs
- Encourage evaluation of pros and cons of behavior change
- Identify and promote new, positive outcome expectations

Preparation:
- Identify and assist in problem solving re: barriers
- Help patient identify social support
- Verify that patient has underlying skills for behavior change
- Encourage small initial steps

Action:
- Focus on restructuring cues and social support
- Bolster self-efficacy for dealing with barriers
- Combat feelings of loss and reiterate long-term benefits

Maintenance:
- Plan for follow-up support
- Reinforce internal rewards
- Discuss coping with relapse

Relapse:
- Evaluate trigger for relapse
- Reassess motivation and barriers
- Plan stronger coping strategies

All of this can probably be evaluated and addressed in a couple of mins - if not - it's unlikely to be practical for the busy family doc.

AMS

WW Orientation Workshop

If my information is currect, there are currently over 2000 people waiting to be assessed in the Adult Weight Management Clinic!

Talking to the folks in the clinic made it quite evident that many of these patients, when they finally get an appointment, are not quite sure what to expect. Many realise that this is not exactly what they want, or the assessing staff quickly finds out that these patients have a lot of other issues that may need to be sorted out first before there is a realistic chance of tackling their obesity.

It is clear that having some form of Orientation Session that will inform potential patients about what the WW program can and cannot offer, what the treatment options are and how much commitment it will take to succesfully conquer their obesity (remember we are dealing with a life-long chronic disease), may help reduce the disappointments and frustrations.

Plans on how best to run these sessions and how best to provide relevant information on the scope of the WW program are currently under development - thanks to everyone who's involved in this! - appreciate any suggestions in this regard.

Happy Thanksgiving everyone,

AMS

New Faculty Orientation

Today was "New Faculty Orientation" day for the Dept of Medicine. Most informative - tons of info - but very useful (though slightly overwhelming). Again, amazed by the friendliness, enthusiasm and the great "can-do" attitude of the folks here in Edmonton.

How does this impact my role as WW-MD? Well, for one, I learnt about the importance of job descriptions and the significance of matching those to my performance review - just double-checked my contract - turns out I have 30% admin in my contract - right now feels like 100% admin - but guess what, I am having a ball!

Every meeting I've been to so far (first one this morning was at 7 - hey, its starting to get CHILLY that early in the morning!) have been helpful and I've come out of every single one of them with the feeling that we are moving things forward - again - great team, great inputs, great enthusiasm!

Thanks everyone - apologies to anyone who thinks today's post is a bit "cheesy" - must be getting soft!

AMS

WiKi Wise

Some of you may be wondering why I would have started this blog in the first place - perhaps unusual for a new director of a healthcare program to want to share my thoughts and seek input from all of you at Weight Wise plus anyone from the general public who should care to comment.

Well - the reason is that I am true "believer" in peer production or "peering". As most of you know, I am also the Director of the Canadian Obesity Network. However, what most of you perhaps don't know is that back in 2005, the entire Network application was written on a "WiKi", created just for the purpose of writing the 30 page grant in less than six weeks! Using an open source WiKi seemed to me quite simply the most sensible way of preparing an application with 120 co-applicants - just imagine the chaos, had we tried to e-mail around various versions of the word document, trying to figure out which version was the latest. To my knowledge this was the first grant application (at least in Canada) to ever have been written using a WiKi.

Those of you who know of Wikipedia, probably appreciate the power of WiKis - but that is just the start - today, WiKis are used by 100s of small and large companies to work collaboratively both within as well as outside the company - and the reason for this is quite simply economic gain - this concept has even spawned the term "Wikinomics" (a must read by Tapscott and Willams!).

The basic idea is that thanks to the internet, the production of goods and services today has become a collaborative activity in which a virtually unlimited number of individuals can participate. Properly implemented, this technology can unlock innovative potential and resources both within and outside an organisation.

The ability fo integrate talents of countless individuals and allow them to participate has been also referred to as Web 2.0. In succesful companies today, employees have an unprecedented knowledge about their firm's strategy, management and challenges - and an unprecendented opportunity to contribute their unique ideas and expertise to their solution. In the end, radical sharing and openness is a win-win for everyone.

"Today", in the words of Tapscott and Williams, "openess, peering, sharing, and acting globally - defines how 21st century corporations compete - very different from the hierarchical, closed, secretive and insular [mentality] that dominated the previous century. The old, harwired "plan and push" mentality is rapidly giving way to a new dynamic "engage and cocreate" economy".

For Weight Wise to become a global leader, this is the kind of philosophy I am keen to adopt.

After only four weeks with Capital Health, I can only be amazed by the enthusiasm, dedication and excitement of the almost 60-70 people who directly or indirectly make up the Weight Wise team (I still don't know quite how many are actually involved). The range of expertise is mind-boggling - a shame not to use every last bit of it to build a truly world class beacon of obesity prevention and care.

Those of you watching us closely will rapidly see an implementation of a variety of Web 2.0 tools that will foster openness, collaboration, information and "participaction". We will have both open and closed systems - all of you will be asked to provide input. There are a number of web-based platforms that allow this type of interaction - I am particularly looking at Socialtext - currently the world leader in open-source WiKi-based collaboration and project management software platforms - but there are others.

In the end, whatever platform we decide to use, all that matters is that all of you can contribute and take true ownership of Weight Wise. Remember, we are up against the biggest chronic disease epidemic ever experienced by mankind - we can certainly use every mind and bright idea that we can muster, if we are to stand a chance in providing prevention and treatments to 100s of 1000s of individuals struggling with overweight and obesity - this blog is only the start of the level of interaction that I seek to implement - look out for more to come.

AMS

Obesity Sensitivity Training

One of the topics that came up at the retreat and should be part of our strategic plan was sensitivity training to avoid bias and discrimination of obese clients. It is certainly no secret that health professionals (like the general public and obese people themselves) often have negative views on obesity which are either implicit or explicit. I can't recall how often I have heard from patients that sometimes complete strangers come up to them and comment on their weight or throw disapproving looks at them, when they eat in public.

If anyone knows how best to go about providing sensitivity training to our team and to other CH employees, I'd love to know. Any links to resources would be most helpful.

In the meantime if you are wondering if you yourself harbor an implicit bias against obese people (or other popular "targets"), you may consider taking a short test at the Project Implicit Site, a virtual laboratory run by three Harvard Scientists at which visitors can examine their own hidden biases. This site allows web visitors to experience the manner in which human minds display the effects of stereotypic and prejudicial associations acquired from their socio-cultural environment. You may be surprised at the results.

AMS

Obesity and Cancer

As probably all of you know, cancer is one of the leading causes of mortality in obese patients, on the other hand treating obesity (at least with bariatric surgery) is associated with a 40-60% reduction in cancer mortality (see the Sjostrom et al. and Adams et al. studies recently published in the NEJM).

I had several conversations/contacts last week about this:

1) Vickie Baracos UofA's Alberta Cancer Foundation Chair in Palliative Medicine, told me about some fascinating data they were collecting on obesity in their cancer patients, hundreds of MRI and CT images were currently being analysed.

2) I learnt that Dr. Tanis Mihalynuk and colleagues from the Alberta Cancer Board were just embarking on an asset mapping exercise regarding community resources on obesity prevention.

3) I also received an e-mail from Dr. Heather Bryant, Vice President & C.I.O., Alberta Cancer Board, Director Division of Population Health & Information, who would like to meet with me on Oct. 9 to discuss the prevention or reduction of obesity which is seen as central to achieving a reduction in cancer incidence.

All of this is very much in line with my own ideas on linking Weight Wise to the Cancer Board activities.

I think we need to develop and implement collaborations with the Alberta Cancer Board and the relevant CH Cancer Services and Programs to:

- recognize the incidence and prevalence of excess weight in cancer patients

- provide information, education and support to cancer patients at risk for weight gain

- provide weight-management services to cancer patients with excess weight

- coordinate cancer screening and treatment services for patients with excess weight seen in the bariatric clinics

Measures of these activities in the area of cancer can include information on the following:

- No. of cancer patients receiving information, education and support to prevent excess weight gain

- No. of cancer patients receiving services for excess weight

- No. of bariatric patients receiving cancer screening and treatment services

There is no question that obesity is a widely ignored issue in cancer patients, both as a risk factor and as a problem following cancer treatments. The increased weight gain seen in some chemotherapy patients is well described, but poorly understood.

As always, I look forward to thoughts and comments,

AMS

Adult Weight Management Retreat, Sept. 19, 2007

This full-day retreat, held at the new Centre for the Advancement of Minimally Invasive Surgery (CAMIS), was the first opportunty for me to meet many of the staff of the WW Adult Weight Management Clinic (AWMC). There were over 20 people in the room representing a wide range of professions including dietetics, nursing, psychology, physiotherapy, social work, medicine and surgery. There was also a good representation of the administrative staff that is key to running a smooth operation.
A number of topics came up that I believe are highly relevant to the smooth running and expansion of the program:
- Integrating new disciplines: while historically the AWMC (or adult bariatric program, as I prefer to call it) started as a dietetic/surgical service, it has rapidly expanded into a full-fledged multi-disciplinary program that will provide a wide range of tertiary-care bariatric services to the region and beyond. Integrating and taking full advantage of the wide range of expertise now available within the group will be an exciting endeavour.
- Patient Intake: This appears to be a key issue for the effective functioning of the clinic. Currently patients, after 2-3 years on the waiting list, enter the assessment clinic with little to no information on what the program can offer. Given the complexity of individual cases, it may well be that patients are not yet prepared to embark on tertiary-care obesity treatments and/or have other significant problems that do not make them good candidates for intervention. Also, intake staff has to spend considerable time explaining the purpose and treatment opportunties in the program. This results in a rather inefficient overall process that needs to be urgently re-engineered. I presented a possible strategy for triaging patients to community services following an "Orientation Workshop", where patients are given information about the program. This Orientation Workshop would be followed by a series of interactive educational community workshops to provide participants essential skills required for long-term weight management.
- Post Surgical Rehab: The suggestion was made to develop a structured post-surgical bariatric rehab program, not unlike rehab programs in other disciplines (e.g. post-MI). Participants would not only (re-) learn essential skills but would also have the opportunity to (re-) engage in social and physical activities, deal with psychological issues arising post surgery and discuss other aspects related to life after bariatric surgery.
-Space: Currently the clinic is operating out of incredibly cramped offices - this situation is hopefully about to change with the idenfication of new office space.
-Continuing Education: Given that bariatric care is such a rapidly evolving field, it is essential that we continue to review best practices in light of new literature. For this purpose, regular "academic" meetings to discuss latest findings and their implications on our program are essential. Attendees were engouraged to join the Canadian Obesity Nework at and sign up for the literature alert services OBESITY+ (for clinicians) or Pre-OBESITY+ (for clinicians and clinical researchers). I also recommended subscribing to the blog "Weighty Matters"
-Staff: It was widely recognized that we urgently need a data-analyst to help monitor the current data flow in the program. While we have the opportunity to collect a large amount of data that could help us improve and streamline our services (and of course address research questions), analysing these data cannot be done without a dedicated analyst. Another important gap that was identified pertained to occupational therapy, an essential piece of bariatric care.
Overall, the day was a resounding success in that it provided attendees with a good overview of the AWMC and provided an opportunity to share some of the strategic plans for making this a world-class program.
Appreciate any comments,
Respectfully,

AMS